COCC Human Resources Office
Phone: (541) 383‐7216
FAX No: (541) 317‐3066
TDD No: (541) 383‐7708
LEAVE REQUEST FORM
Employee _______________________________________________________________ Date: ______________________
COCC ID # ____________________________________________________________________________________________
Department __________________________________________________________________________________________
Dates/Hours Requested ____________________________________________________________________________
________________________________________________________________________________________________________
Type of Leave:
REMINDER: EMPLOYEES MAY NOT UTILIZE VACATION LEAVE DURING THE FIRST SIX
MONTHS OF EMPLOYMENT.
If "vacation" time is requested within the first 6 months, the approved time off must be applied as
‘Leave Without Pay’.
Vacation Comp time Leave Without Pay Bereavement* Emergency Leave
Personal Leave (Faculty requests require VPI approval) Religious Observance
Sick Leave For: Self or Family(relationship_______________________)
* If Bereavement Leave is requested, please also complete the Bereavement Leave Request form
Employee Signature: ___________________________________________________ Date_______________________
Supervisor’s Signature: ________________________________________________ Date_______________________
VPI Signature: __________________________________________________________ Date_______________________
INSTRUCTIONS:
1. All leave requests must be APPROVED before the leave is taken.
2. The employee and Supervisor each keep a COPY of the approved request.
3. The SUPERVISOR SENDS the approved leave form to Payroll in Newberry Hall.
4. If the approved time is not taken, it is the employee’s responsibility to submit a revised leave
request form to the Supervisor for signature and forwarding to Payroll.
5. Classified staff must report approved leave on monthly time sheets.
Please print this form, fill out, sign and send to:
Payroll Newberry Hall
2600 NW College Way
Bend, Oregon 97701‐5998 Revised 05/17/2017
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome